Provider Demographics
NPI:1841553088
Name:BROADBENT, MARK AARON (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:AARON
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 FAWCETT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1900
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:
Practice Address - Street 1:2502 S UNION AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1328
Practice Address - Country:US
Practice Address - Phone:253-841-4653
Practice Address - Fax:253-446-3973
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1887952085R0202X, 2085N0700X
WAMD608374292085R0202X, 2085N0700X
MO20170086372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0389199OtherLNI-DINW
OR500744919Medicaid
WA0389197OtherLNI-TRA KING COUNTY
WA0389198OtherLNI-UAOM
WA0389196OtherLNI-TRA REST OF WA
WA2097736Medicaid